Provider Demographics
NPI:1841920352
Name:BLACKBOURN, MIRANDA RENE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENE
Last Name:BLACKBOURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 BERNARD ST APT 732
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-7194
Mailing Address - Country:US
Mailing Address - Phone:713-494-9586
Mailing Address - Fax:
Practice Address - Street 1:1115 3RD ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2170
Practice Address - Country:US
Practice Address - Phone:231-722-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator